Prior to scheduling an appointment, this form must be submitted via mail/fax/email to ensure that you meet genetic testing criteria. You will then receive a call to schedule an appointment with the genetic counselor.

Michelle Weinberg, MS, CGC

425 West 59th Street, Suite 7A

New York, NY 10019

P: 212-523-7092 F: 212-523-7012

Genetics Consult Intake
Name: / DOB: / Age:
CONTACT INFORMATION
Address / Street:
City: / State: / Zip:
Phone / Home: / Work: / Cell:
Preferred Contact Number: / Home / Work / Cell / May We Leave Messages: / Yes / No
Email / May We Contact You By Email: / Yes / No
INSURANCE INFORMATION
Insurance Provider: / Policy #/Member ID:
Subscriber Name and DOB: / Relationship: / Self / Spouse / Child / Other
REFERRAL SOURCE
Referring Physician:
Address / Street:
City: / State: / Zip:
Phone / Office: / Fax:

CANCER HISTORY

1. Have you ever been diagnosed with cancer? No___ Yes___
If yes, please indicate the site(s) of the cancer and at what age you were diagnosed.
______
______
______
-______
2. Do you have a family history of cancer? / No / Yes
If yes, please complete the table below for each family member, indicating their relationship to you, maternal or paternal relative, type of cancer, and age at which they were diagnosed with cancer. If more space is needed, please continue onto the back of this paper.
Relationship / Maternal (M) or Paternal (P) / Type/Site of Cancer / Age at Diagnosis
Example
Grandmother / M / Breast / 51

PERSONAL HISTORY

Please indicate your approximate: Height____ Weight____
1. How old were you when you had your first menstrual period? Age: _____
Do you still have your menstrual period? No___ Yes ___
If no, at what age did you stop having your period? Age: _____
2. Have you ever been pregnant? No___ Yes___
If yes, list the number of pregnancies: ______
If yes, list the number of live births: ______Age at first delivery:______
3. Please indicate if you have used the following:
Birth control pills: No___ Yes___ Number of years total: _____
Fertility treatments: No___ Yes___ Type: ______Total length of time: ______
Estrogen or hormone replacement therapy: No__ Yes___ Age range: ______
Thyroid hormone: No___ Yes___ Age range: ______
4. Have you ever had a clinical breast exam? No___ Yes___ If yes, date of last exam: ______
Have you ever had a breast sonogram/ultrasound? No___ Yes___
If yes, list the date of your last sonogram. Date:______Frequency: ______
Have you ever had a breast mammogram? No___ Yes___
If yes, list the date of your last mammogram. Date:______Frequency: ______
Have you ever had a breast MRI? No___ Yes___
If yes, list the date of your last MRI. Date:______Frequency: ______
Have you ever had a breast biopsy? No___ Yes___
If yes, how many in total? ______
______
-______
5. When was your last pelvic exam with a gynecologist? Date:______Frequency: ______
Have you ever had a transvaginal ultrasound outside of pregnancy? No___ Yes___
If yes, list the date of your last ultrasound. Date:______Frequency: ______
Have you ever had your uterus or ovaries removed? No___ Yes___
If yes, indicate: Uterus___ Both ovaries___ One ovary ___ / Age at surgery: ______
If yes, what was the indication for the surgery? ______
Have you ever had blood drawn for a CA-125? No___ Yes___
If yes, list the date of your last test. Date:______Frequency: ______
6. Have you ever had a colonoscopy? No___ Yes___
If yes, please list the indication(s)? ______Date of last colonoscopy:______
If yes, how often has your gastroenterologist recommended that you return?
Frequency: ______Next appointment ______
If yes, have any colon polyps been removed? No___ Yes___
How many polyps total? ______
-______
7. Have you ever had skin exam performed by a doctor? No___ Yes___
If yes, list the date of your last skin exam. Date:______Frequency: ______
-______
8. Please indicate other relevant medical and surgical history:
______
______
______
______
______
9. Please indicate if you have had cancer genetic testing before, or if anyone in your family has been found to carry a cancer-related genetic mutation. ______
______
10. Please indicate your ethnicity (ies)______Any Ashkenazi Jewish descent? No___ Yes___

SOCIAL HISTORY

1. Do you work outside the home? No___ Yes___ If yes, list your occupation: ______
2. Please indicate your level of physical activity:
Very active___ Moderately active___ Somewhat active___ Sedentary___
3. Please indicate your diet:
High fat___ Medium fat ___ Low fat___
4. Any history of smoking? No___ Yes___ Quit___ When? ___
If yes, indicate the total number of years and quantity:
Years:______Amount: ______cigarette(s)/pack(s)/day(s)/week(s)
5. Have you been exposed to any abnormal agents (e.g., asbestos)?
______
-______